=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114111051
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DR. LEA A. CORNISH, P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/04/2007
-----------------------------------------------------
Last Update Date | 06/21/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 624 W VETERANS PKWY SUITE A
-----------------------------------------------------
City | YORKVILLE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60560-2505
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-385-6200
-----------------------------------------------------
Fax | 630-385-8526
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 624 W VETERANS PKWY SUITE A
-----------------------------------------------------
City | YORKVILLE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60560-2505
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-385-6200
-----------------------------------------------------
Fax | 630-385-8526
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. LEA ANN CORNISH
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 630-385-6200
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 038-007230
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------